Dispelling Myths About Surgery’s Role in Global Health

Friday, March 27, 2015

The past few decades have seen enormous changes in the global burden of disease. Although many people, especially those living in (or near) poverty and other privations, are familiar with heavy burdens and much disease, the term “global burden of disease” emerged in public health and in health economics only in recent decades. It was coined to describe what ails people, when, and where, and just as reliable quantification is difficult, so too is agreeing on units of analysis. Does this term truly describe the burden of disease of the globe? Of a nation? A city?

We have also learned a thing or two about how to assess this global burden, and how to reveal its sharp local variation and transformation with changing conditions ranging from urbanization to a global rise in obesity. Measuring illness has never been easy, nor has attributing a death—whether premature or at the end of fourscore years—to a specific cause. Even countries with sound vital registries generate data of varying quality, given that cause of death is rarely confirmed by autopsy. When nonlethal or slowly debilitating illness is added to considerations of burden of disease, the challenge of both measurement and etiologic claims can appear overwhelming.

The challenges of measuring the burden of disease only get more complex when attempting to use the category of surgical disease. For starters, even experts do not agree on definitions of ostensibly simple terms such as “surgical disease”. Some illnesses rarely considered to be surgical problems pose threats to health if neglected long enough. Some trends are clear, however. Take the examples offered by Haiti and Rwanda, where different types of trauma (intentional or the result of crush injuries) account for a majority of young-adult deaths. How many of these deaths are classified as attributable to surgical disease?

A sound grasp of the burden of disease is essential to those seeking data-driven methods to design and evaluate policies aimed at decreasing premature death and suffering. But surgical disease was not often on the agenda. The immensity and complexity of the task of quantifying the surgical burden of disease has led many to avoid that task, leading to an analytic vacuum with adverse consequences.

For too long, the global health movement has failed to count surgery as an integral part of public health. Prevailing wisdom dictated that the surgical disease burden was too low, surgical expenses too high, and delivery of care too complicated.